Consistent measures and terminology of care-related patient harm are still needed in health care. This commentary reviews inconsistencies in the nomenclature used in studies of harm as well as limitations of existing harm classification tools. The authors propose a tool that provides a process for developing a standard classification score to record medication-related patient harm.

Journal Article > Commentary

The design of research in patient safety has garnered controversy. This commentary suggests that approaches beyond the randomized controlled trial are needed to spur the rapid development of evidence needed to drive progress.

Journal Article > Review

Health care leaders have embraced applying safety sciences methods to improve care delivery. This review discusses the evolution of health care safety from focusing on reactive analysis and response to error (Safety-1) to one that seeks to prevent errors through emphasizing safe system design (Safety-2). The authors advocate for developing a resilient system to examine what works well and incorporate those practices into daily work.

Journal Article > Review

Situational awareness during critical incidents is a key component of teamwork. This review spotlights the importance of situational awareness in health care and provides information about how to assess and develop it in individual clinicians and among team members.

Journal Article > Study

The frequency of diagnostic errors in outpatient care remains unclear. In this survey of outpatient general pediatricians, about one-third reported making a diagnostic error every month. This finding underscores the importance of enhancing the safety of diagnosis in ambulatory settings.

Journal Article > Commentary

Peer review can provide clinicians with the opportunity to learn from failure. However, insufficient understanding of medical error, process complexity, and a penchant for blame can limit its effectiveness. This commentary suggests that standards for peer assessment specific to error must be developed to achieve learning from mistakes.

Journal Article > Commentary

Despite the perceived value of publicly available quality and safety data, concerns have been raised about their effectiveness. Reviewing the evidence on existing patient safety measures, this commentary explores the accuracy, validity, and usefulness of information reported. The authors suggest that clinicians and health care consumers be involved in designing metrics and collecting data to improve public reporting systems.

This educational study found that an objective structured medical examination, in which a learner's interaction with a standardized patient is observed by a trained clinician, can reliably assess learner competence in safety culture. This suggests that safety culture cases could be added to existing clinical examinations in patient safety.

Journal Article > Study

This direct observation study examined cognition among experienced clinicians in the setting of their recertification examination and found that when they changed answers, it was usually from an incorrect to a correct response. This suggests that further reflection enhances accuracy compared to intuitive response, consistent with work on metacognition to enhance diagnostic accuracy.

Book/Report

This report summarizes concerns reported in an annual survey of junior doctors in the United Kingdom, reviews how these issues have been addressed, and uses case studies to illustrate the role of reporting systems in tracking perceived patient safety hazards.

This before-and-after study found that introduction of a tiered alert system for medication dosages in pediatric patients led to an increase in alerts, but also resulted in fewer overridden alerts and more medication order revisions. This work emphasizes the need to improve electronic medication alerts to make them more actionable and reduce alert fatigue.

Journal Article > Study

Unnecessary prescribing of antibiotics for viral conditions can pose patient safety risks. This study found that primary care physicians are more likely to prescribe antibiotics inappropriately toward the end of their clinic session (late morning or late afternoon), which likely represents clinicians' decision fatigue.

Journal Article > Commentary

Exploring the existing evidence on interruptions in health care, this commentary reveals that most studies focus on the rate of interruptions rather than the relationship between interruptions and errors. The author calls for research to evaluate how use of multitasking behaviors to manage interruptions and to differentiate between appropriate interruptions that prevent errors and those that contribute to preventable harm.

Journal Article > Commentary

This commentary spotlights the importance of learning about cognitive science to understand and improve diagnostic reasoning in order to prevent errors. Underscoring limits of the Hippocratic Oath, the authors describe the ethical responsibility of individuals and organizations to augment clinical decision-making, judgment, and critical thinking skills as an integral component of professionalism.

In this study, 5% of children who were hospitalized at a community hospital were initially misdiagnosed in the emergency department. Although the physicians in the study believed that their diagnostic errors were primarily due to system-related factors, independent reviewers largely attributed these errors to cognitive biases.

Journal Article > Commentary

This commentary discusses how two medical centers utilized the fishbone diagram as a tool to analyze diagnostic errors. A health care facility in Maine developed a root cause analysis model to determine common factors, and a residency program in Pennsylvania introduced a modified fishbone diagram to educate trainees about cognitive biases and systems issues.

Web Resource > Multi-use Website

Diagnostic errors have been termed the next frontier in patient safety. This Web site highlights the work of a group committed to analyzing the problem in depth to determine evidence-based solutions. Materials created in conjunction with the project will be summarized here as work progresses.